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All major Credit Cards accepted
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*FIRST NAME(S)...................................................................
*LAST (FAMILY) NAME...................................................................
*Date Of Birth. .......... / .......... /..........
*EMAIL...................................................................
*YOUR SEX (GENDER); MALE / FEMALE
*ADDRESS...................................................................
*ADDRESS...................................................................
*POST / ZIP CODE ..........................
*TEL.NO...................................................................
FAX...................................................................
| *DO
YOU SUFFER FROM ERECTILE DYSFUNCTION (IMPOTENCE)?
|
______ |
| *ANGINA? | ______ |
| *ACTIVE DUODENAL OR STOMACH ULCERS? | ______ |
| *SICKLE CELL ANAEMIA? | ______ |
| *LEUKAEMIA? | ______ |
| *MULTIPLE MYELOMA? | ______ |
| *HIGH BLOOD PRESSURE? | ______ |
| *DO
YOU RECEIVE ANY TREATMENT FOR HEART PROBLEMS?
|
______ |
| *DO
YOU SUFFER FROM ANY ABNORMALITY OF THE PENIS?
|
______ |
| *ARE YOU TAKING ANY MEDICATION (EITHER PRESCRIBED OR OVER-THE-COUNTER)
Viagra must NEVER be taken in combination with NITRATE-based drugs including Amyl-Nitrates.
At your next medical consultation, please remember to tell your doctor that you are taking Viagra. | ______ |
| *DO
YOU HAVE ANY KNOWN ALLERGIES?
|
______ |
| *HAVE YOU BEEN PRESCRIBED VIAGRA (OR ANOTHER IMPOTENCE TREATMENT) BEFORE?
|
______ |
| *I accept total responsibility for having a routine physical examination (including blood test) and I have had one in the last 12 months. | ______ |
| *IS
THERE ANY REASON WHY YOU BELIEVE YOU MAY NOT BE ABLE TO TAKE VIAGRA?
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______ |
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| I confirm that I have read and understood the information given and that the above information is the truth to my certain knowledge. I know of no reasons why I should not be prescribed Viagra and I believe that this consultation by the DRM appointed doctor is in my best interest as a patient. I accept full responsibility for my use of the supplied drugs. | *Signed____________________
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If you already have a prescription for Viagra from your own doctor, please enclose it with your order.
TOTAL DISCRETION IS ASSURED - YOUR MEDICAL DETAILS WILL NEVER BE PASSED ON TO A THIRD PARTY
ORDER FORM 
PLEASE INDICATE THE QUANTITY YOU REQUIRE;-
4 x 50mg tablets = £70.00 |
_____ |
8 x 50mg tablets = £120.00 |
_____ |
16 x 50mg tablets = £232.00 |
_____ |
24 x 50mg tablets = £336.00 |
_____ |
32 x 50mg tablets = £432.00 |
_____ |
4 x 100mg tablets = £80.00 |
_____ |
8 x 100mg tablets = £150.00 |
_____ |
16 x 100mg tablets = £296.00 |
_____ |
24 x 100mg tablets = £432.00 |
_____ |
32 x 100mg tablets = £560.00 |
_____ |
£ = $?, FrF?, Kr?, DM?, YOUR COUNTRIES CURRENCY? - EXCHANGE - CHANGE - CONVERT
NO SEPARATE CONSULTATION FEE - NO HIDDEN COSTS - POSTAGE AND PACKING TO ANY COUNTRY INCLUDED
(DRM are not responsible for local taxes or import restrictions which may apply in your country)
Please debit my Access / Visa / Mastercard No ............. / ............. / ............. / .............
Expires ............. / ..............
DESPATCH TO;
NAME ..................................................................................................................
ADDRESS ............................................................................................................
.............................................................................................................................
COUNTRY...............................................................................................................
POST CODE ................................. EMAIL...........................................................
NAME & ADDRESS ON CREDIT CARD (if different) ...............................................
.............................................................................................................................
.............................................................................................................................
HAVE YOU ORDERED via drm BEFORE ? - - - YES / NO
HOW DID YOU LEARN OF DRM?... Search engine / Newspaper / Magazine / Website link / Other
Please Specify ..............................................................................................................................
If you were referred to DRM from another website, please specify;
..............................................................................................................................
If a search engine, what search word(s) did you use?
..............................................................................................................................
Fax or post your completed forms to;-
Direct Response Marketing Limited.
Suite 15 Burlington House, St Saviours Road, St Helier, Jersey. Channel Islands. JE2 4LA. Telephone; 0845 121 6667 (UK local rate) Fax; 0845 121 6669 (UK local rate) International Telephone (44) 1534 510271 International Fax (44) 1534 510272General Enquiries - email: Email DRM
Order Enquiries - email: Email order dept
VIAGRA is the registered trademark of Pfizer Inc. NY.
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In association with 
Currency rates are provided for guidance only
| Convert | into |
Quote
technology by TIBCO, a Reuters company.
Quote data provided by Reuters Limited.
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Propecia is the trademark of Merck & Co., Inc. Viagra is the registered trademark of Pfizer Inc. NY. All other trademarks are acknowledged as being the property of their respective owners |
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